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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION • FORM B i' COMPLETE A SEPARATE FORM FOR EAC NK SYSTEM MARK ONLY 1 NEW PERMIT ❑ 3 RENEWAL PERMIT S CHANGE OF INFORMATION 7 PERMANENTLY CLOSED ON SITE ONE REM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ e TANK REMOVED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: jrdS 'eF- CG,t�T,-aril W I. TANK DESCRIPTION COMPLETE ALL ITEMS— SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.• O/ S. MANUFACTURED RY: (�[� C. DATE INSTALLED(MOIDAYNEAR) v D. TANK CAPACITY IN GALLONS: ,�v II.TANKCO EMS IF A l IS MARKED,COMPLETE ITEM C. A 1 MOTOR VEHICLE FUEL ❑ 4 OILB. C. 1:1 la REGULAR IESEL ❑ 6 AVIATION GAS ❑ 2 PETROLEUM O 90 EMPTY 1 PRODUCT E] lb PREMIUM 4 GASAHOL ❑ 7 METHANOL UNLEADED 5 JETFUEL ❑ 3 CHEMICALPRODUCT O 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED 99 OTHER (DESCRIBE IN ITEM O. BELOW) D. IF(A1)IS NOT MARKED. ENTER NAME OF SUBSTANCE STORED C.A.S.or 111. TANK CONSTRUCTION MARK ONE ITEM ONLY IN BOXES A.B.ANDC.AND ALLTHAT APPLIES IN BOX CARD A. TYPE OF ❑ BLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM jY GLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTEDTANK) ❑ 99 OTHER S. TANK ED", BARE STEEL ❑ 2 STAINLESS STEEL ❑ 3 FIBERGLASS ❑ 4 STEELCLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 6 100% METHANOL COMPATIBLE W/FRP (PfimaryTank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 96 UNKNOWN ❑ 99 OTHER ❑ 1 RUBBER LINED KYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING C.INTERIOR ❑ 5 GLASS LINING 6 UNLINED ❑ 95 UNKNOWN ❑ 00 OTHER LINING IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES_ NO_ D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ ATING ❑ 3 VINYL WRAP ❑ 4 FIBERGLASS REINFORCEO"PLASTIC �._---- PROTECTION ❑ 5 CATHODIC PROTECTION 91 NONE ❑95 UNKNOWN 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEMTYPE A U BUCTI A U 2 PRESSURE A U 3 GRAVITY A U w OTHER B. CONSTRUCTION A U SINGLE WALL A U 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A UIQARE 5 EEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A U 4 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U B 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL. A U 10 CATHODC PROTECTION A U 95 UNKNOWN A U 99 OTHER D. LEAK DETECTION [:D 1 AUTOMATICLEAK DETECTOR E] 2 LINE TIGHTNESS TESTING ❑ MONITORING ❑99 OTHER V.TANK LEAK DETECTION HE 1 VISUAL CHECK 2 INVENTORY RECONCILIATION ❑ 3 VADOZE MONITORING ❑ 4 AUTOMATIC TANK GAUGING ❑ 5 GROUND WATER M6 TANK TESTING ❑ 7 INTERSTITIAL MONITORING F791 NONE ❑ 95 UNKNOWN ❑ 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATELAST SED( IDAV/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES [D NO SUBSTANCE REMAINING 0 GALLONS INERT MATERIAL? THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANTS NAME DATE IPRINTEp a SIGHATUREI LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OF THE FOUR NUMBERS BELOW COUNTY# JURISDICTION# FACILITY# TANK# leEAL.rr,� l STATE I.D.# ERMXIRATNN TPERMITNUMBER PERMIT APPROVED BYIDATE P Z_ FORM B (7-91) THIS FORM MUST BE ACCOMPANIED BY APERMIT APPLICATION•FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. FOR70MSM /